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State of California
Secretary of State
 
REGISTRATION OFWRITTEN ADVANCE HEALTH CARE DIRECTIVE
(Probate Code sections 4800-4805)
 
File # ______________________________ 
IMPORTANT - Read all instructions before completing this form.
This Space For Filing Use Only
1. CHECK THE APPLICABLE BOX (NOTE: CHECK ONLY ONE BOX)
New Registration..............
 
For a new registration, check this box and complete the entire form.
There is a $10.00 filing fee forregistration of a new directive.
 Amendment......................
 
For an amendment to a previously filed registration form (not the directive), check this box, completeItems 3 and 7 and the appropriate section that changed. There is no filing fee.Revocation Only...............
 
For a revocation (change) of a written advance health care directive that has been registeredpreviously with the Secretary of State
or 
a revocation of your registration, check this box and completeItems 3 and 7. There is no filing fee.Revocation (change)........of Prior Directive andNew RegistrationFor a revocation (change) of a written advance health care directive that has been registeredpreviously and the registration of a new directive, check this box and complete the entire form.
Thereis a $10.00 filing fee for registering the new directive.
 
2. CHECK THE APPLICABLE STATEMENT(S):
The written advance health care directiveis attachedThis serves as notification of intended place of deposit or safekeeping of awritten advance health care directive
 
3. REGISTRANT’S INFORMATION:
NAME (LAST) (FIRST) (MIDDLE)STREET ADDRESS CITY AND STATE ZIP CODEDATE OF BIRTH PLACE OF BIRTH
 
ENTER AT LEAST ONE ITEM:
a. Social Security Number b. Driver’s License Number and State or Country Issuing c. Other Identifying Number Established By Law and State orCountry Issuing
4. AGENT INFORMATION
(if any)
:
NAME (LAST) (FIRST) (MIDDLE)HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER
( ) ( )
5. ALTERNATE AGENT INFORMATION
(if any)
:
NAME (LAST) (FIRST) (MIDDLE)HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER
( ) ( )
6. INTENDED PLACE OF DEPOSIT OR SAFEKEEPING OF THE WRITTEN ADVANCE HEALTH CARE DIRECTIVE
(if applicable)
:7.
SIGNATURE OF REGISTRANT DATETYPE OR PRINT NAME OF REGISTRANT
SFL-461 (REV 06/2006) APPROVED BY SECRETARY OF STATE
 
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